Hamstring撕脱性骨折的影像学诊断

David Shulman, Harvard Medical School III Gillian Lieberman, MD IMAGING OF HAMSTRING AVULSION INJURIES: DIAGNOSTIC, PROGNOSTIC AND TREATMENT IMPLICATIONS David Shulman, 2013 Gillian Lieberman, MD AGENDA • Patient presentation • Regional anatomy • Presentation and epidemiology • Diagnostic imaging • Implications for treatment • Conclusion of patient presentation • Imaging of chronic hamstring injuries David Shulman, 2013 Gillian Lieberman, MD OUR PATIENT: HISTORY • 76-year-old man presented to the emergency room with sharp pain in the right posterior thigh • Sudden onset while running • 2/10 at rest • 10/10 with any active movement • No prior history of lower extremity injury David Shulman, 2013 Gillian Lieberman, MD OUR PATIENT: EXAM • Extremities: • Pelvis stable and non-tender • No swelling, overlying ecchymosis, or palpable defect in muscles/tendons of posterior thigh • Tenderness to palpation over right superior posterior thigh • Active contraction of right hamstring limited by pain David Shulman, 2013 Gillian Lieberman, MD OUR PATIENT: PLAIN FILM David Shulman, 2013 Gillian Lieberman, MD PACS-BIDMC OUR PATIENT: FURTHER HISTORY • Given the patient’s history, there was high suspicion for a muscle tear • An MRI was ordered for two days after the injury David Shulman, 2013 Gillian Lieberman, MD OUR PATIENT: MRI - ISCHIAL TUBEROSITY David Shulman, 2013 Gillian Lieberman, MD PACS-BIDMC MRI Axial - T1 C- MRI Axial - T2 C- OUR PATIENT: MRI - BASE OF ISCHIAL TUBEROSITY PACS-BIDMC David Shulman, 2013 Gillian Lieberman, MD Findings: • Normal tendon attachment • Absent tendon attachment • Edema and hemorrhage MRI Axial - T1 C- MRI Axial - T2 C- OUR PATIENT: MRI - 1 CM BELOW ISHCIAL TUBEROSITY PACS-BIDMC David Shulman, 2013 Gillian Lieberman, MD MRI Axial - T1 C- MRI Axial - T2 C- OUR PATIENT: MRI - 2 CM BELOW ISCHIAL TUBEROSITY PACS-BIDMC David Shulman, 2013 Gillian Lieberman, MD MRI Axial - T1 C- MRI Axial - T2 C- OUR PATIENT: MRI - 4 CM BELOW THE ISCHIAL TUBEROSITY PACS-BIDMC David Shulman, 2013 Gillian Lieberman, MD Avulsed tendon head MRI Axial - T1 C- MRI Axial - T2 C- OUR PATIENT: MRI CORONAL David Shulman, 2013 Gillian Lieberman, MD MRI Coronal - T1 C- MRI Coronal – STIR C- PACS-BIDMC Findings: • Normal tendon attachment • Avulsed tendon OUR PATIENT: MRI - EXPANDED David Shulman, 2013 Gillian Lieberman, MD PACS-BIDMC Ischial tuberosity Tendon MRI Coronal - T1 C- MRI Coronal – STIR C- DIFFERENTIAL DIAGNOSIS Posterior thigh pain • Hamstring strain • Ischial tuberosity disease • Hamstring enthesopathy • Hamstring syndrome • Referred pain • Hamstring contusion • Myositis ossificans • Bursitis • Ligament strain • Posterior compartment syndrome • Sciatic nerve pain • Bone tumor • Sacroiliitis • Claudication Radiologic differential for hamstring muscle complex injury • Hamstring strain • Hamstring avulsion/tear w/ or w/o ischial tuberosity involvement David Shulman, 2013 Gillian Lieberman, MD REGIONAL ANATOMY David Shulman, 2013 Gillian Lieberman, MD • Flex the knee and extend the hip • The hamstring muscles cross two joints, predisposing to strains and tears • Decelerates the leg during running and walking Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics. 2005 May-Jun;25(3):571-86. Review. Erratum in: Radiographics. 2005 Sep-Oct;25(5):1436. REGIONAL ANATOMY – TENDON ATTACHMENTS David Shulman, 2013 Gillian Lieberman, MD Semimembranous Tendon Conjoint Tendon Muscle body Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics. 2005 May-Jun;25(3):571-86. Review. Erratum in: Radiographics. 2005 Sep-Oct;25(5):1436. PACS-BIDMC PRESENTATION AND EPIDEMIOLOGY • History • Sudden onset • Feeling of a “pop” • Pain is exacerbated by movement of the leg • Epidemiology and risk factors • Adolescents - Avulsion of the ischial tuberosity is more common • Adults - Involvement of the muscle-tendon junction • Elderly – Tendon involvement most common • Poor flexibility and muscle weakness relative to the quadraceps • Sports related – Waterskiing, sprinting, playing soccer and football David Shulman, 2013 Gillian Lieberman, MD Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics. 2005 May-Jun;25(3):571-86. Review. Erratum in: Radiographics. 2005 Sep-Oct;25(5):1436. IMAGING HAMSTRING AVULSIONS: GOALS • Diagnosis • Prognosis • Determine surgical candidacy David Shulman, 2013 Gillian Lieberman, MD IMAGING HAMSTRING AVULSIONS: MODALITIES • X-ray • Often first study in practice • May help identify bony abnormalities and joint abnormalities • Ultrasound • Most sensitive early for moderate to severe injuries • Slightly more sensitive than MRI in the first two weeks, but declines as fluid resolves 1 • US may be most sensitive in adolescents2 • MRI • Improved characterization of the injury • More prognostic information • Useful for following injury resolution 1. Connell DA, Schneider-Kolsky ME, Hoving JL, Malara F, Buchbinder R, Koulouris G, Burke F, Bass C. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol. 2004 2. Lazović D, Wegner U, Peters G, Gossé F. Ultrasound for diagnosis of apophyseal injuries. Knee Surg Sports Traumatol Arthrosc. 1996;3(4):234-7 David Shulman, 2013 Gillian Lieberman, MD RADIOLOGIC FINDINGS ON X-RAY Gidwani S, Bircher MD. Avulsion injuries of the hamstring origin - a series of 12 patients and management algorithm. Ann R Coll Surg Engl. 2007 May;89(4):394-9. David Shulman, 2013 Gillian Lieberman, MD Ischial tuberosity avulsion RADIOLOGIC FINDINGS ON US • Heterogenetity of the HMC tendons • Surrounding edema • Separation of conjoint and semimembranous tendons from the ischial tuberosity • Can look for movement of the muscle tendon complex David Shulman, 2013 Gillian Lieberman, MD RADIOLOGIC FINDINGS ON US: EXAMPLES A B Ultrasound imaging showing a partial tear of the HMC (arrow) near the insertion point on the ischial tuberosity (*). Fluid can be seen tracking under the tendon complex (curved arrow). Ultrasound imaging showing a normal HMC (arrow) near the insertion point on the ischial tuberosity (*). Superior to the insertion the HCM is difficult to separate from the sacrotuberous ligament (curved arrow). Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics. 2005 May-Jun;25(3):571-86. Review. Erratum in: Radiographics. 2005 Sep-Oct;25(5):1436. David Shulman, 2013 Gillian Lieberman, MD RADIOLOGIC FINDINGS ON MRI • Tendons are low-intensity on MR • Loss of low-intensity signal between tendons and bone may be visible on T1 • Intervening edema between tendons and bone will be evident on T2 • On T2 imaging fluid may be seen tracking down the posterior compartment around the hamstrings. • May be able to assess sciatic nerve integrity David Shulman, 2013 Gillian Lieberman, MD RADIOLOGIC FINDINGS ON MRI: PARTIAL TEAR David Shulman, 2013 Gillian Lieberman, MD Courtesy of Dr. James Wu • Partial tear • Tendon is largely intact • Subtle high-intensity edema around tendon TREATMENT • Most evidence comes from small case studies • No definitive guidelines for surgical vs. non-surgical management • Most patient’s do well with non-operative management • Elite athletes may benefit from surgical management • Avulsion of the ischial tuberosity in adolescents may warrant surgical correction David Shulman, 2013 Gillian Lieberman, MD OUR PATIENT: CONCLUSION • The orthopedic surgeon decided to treat non-operatively • The patient is currently undergoing physical therapy David Shulman, 2013 Gillian Lieberman, MD COMPLICATIONS OF HAMSTRING AVULSIONS David Shulman, 2013 Gillian Lieberman, MD MRI – sagital – T1 MRI – coronal – T2 FS • Re-injury • Sciatic nerve irritation • Myositis Ossificans • “Hamstring syndrome” Personal collection CONCLUSIONS • Hamstring injuries are a common musculoskeletal problem • The choice to image should be based on the history and physical examination • Imaging modality may be patient specific and depend on the availability of technology • US and MRI are the two most sensitive technologies • US is operator dependent, most sensitive early and best for moderate to severe injuries • MRI provides overall assessment of the injury, surgical characterization and the potential for long-term monitoring David Shulman, 2013 Gillian Lieberman, MD ACKNOWLEDGMENTS • Dr. Gillian Lieberman • Claire Odom • Dr. Jim Wu • My family • Roshan Sethi, HMS III David Shulman, 2013 Gillian Lieberman, MD